R95-141 AUTHORIZING APPLICATIONS FOR GROUP HEALTH INSURANCE COVERAGE

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payable to the Claim Administrator by the Employer for Claim Payments provided by the Claim Admin- I • istrator and applicable service charge(s) pursuant to the terms of this Agreement and all required de- ductible and Coinsurance amounts under this Agreement shall be calculated on the basis of the Pro- vider's Eligible Charge for Covered Services rendered to a Covered Person, irrespective of any separate financial arrangement between any Administrator Provider or the Employer and the Claim Administrator. A. ACCESS FEES From time to time Covered Persons may receive health care services outside Illinois and from I a Provider which does not have a contract with the Claim Administrator for the provision of, and II payment for, such health care services. Under such circumstances the Blue Cross and Blue , Shield Plan in the particular state in which such services are received (the "Host Plan") will pro- ' cess the Covered Person's Claim in accordance with the Host Plan's applicable contract, if any, I with the particular Provider("Host Plan Provider"). Host Plans may charge the Claim Administra- tor an access fee for making their negotiated payment rates and the resulting savings available on Claims incurred by Covered Persons under this Agreement.This access fee, if one is charged, � may be up to 10% (but not to exceed $2,000 for any Claim) of the resulting savings. When the Claim Administrator is charged an access fee by a Host Plan for such services, such fee shall be considered and treated as a Claim Payment under this Agreement. If the Claim Administrator receives any credit relative to such access fee from the Host Plan, such amount shall be credited against Claim Payments under this Agreement. Instances may occur in which no Claim Payment or a minimal Claim Payment is made under this Agreement because the amounts eligible for payment were applied to the deductible or Coinsu- rance. Nonetheless, if the Host Plan charges the Claim Administrator an access fee as discussed � above relative to such Claim, the Claim Administrator shall pay such fee and such amount shall be considered and treated as a Claim Payment under this Agreement. B. SERVICES RENDERED OUT OF CLAIM ADMINISTRATOR'S SERVICE AREA From time to time, Covered Persons may receive health care services outside Illinois and from a Provider which does not have a contract with the Claim Administrator for the provision of, and payment for, such health care services. Under such circumstances, the Blue Cross and Blue Shield Plan in the particular state in which the services are received(the"Host Plan")will process the Covered Person's Claim in accordance with the Host Plan's applicable contract, if any, with the particular Provider ("Host Plan Provider"). The Claim Administrator hereby informs the Employer and all Covered Persons that certain Host Plans may have contracts with Host Plan Providers under which in certain circumstances described therein, the Host Plan may receive substantial payment from Host Plan Providers with respect to services rendered to Covered Persons for which the Host Plan was obligated to pay the Host Plan Provider, or the Host Plan may pay Host Plan Providers less than their billed charges for services, by discounts or otherwise, or may receive from Host Plan Providers other allowances under the Host Plan's contracts with them.The Employer acknowledges that in nego- tiating the premiums and/or Service Charges set forth in this Agreement, it has taken into account that, among other things, the Host Plan may receive such payments, discounts and/or other allowances during the term of this agreement with the Claim Administrator. Further, all amounts payable to the Host Plan by the Claim Administrator for Claim Payments made by the Host Plan and applicable Service Charges thereon and any required deductible and Coinsurance amounts • under the Agreement, may be calculated on the basis of the Host Plan Provider's Claim Charge for Covered Services rendered to a Covered Person, irrespective of any separate financial arrangement between the Host Plan Provider and the Host Plan as referred to herein. - 8 -